Provider Demographics
NPI:1922647213
Name:ADAMS, DERALD NICK (EDS)
Entity Type:Individual
Prefix:MR
First Name:DERALD
Middle Name:NICK
Last Name:ADAMS
Suffix:
Gender:M
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:458 OLD CHEROKEE RD STE 203
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-6971
Mailing Address - Country:US
Mailing Address - Phone:803-250-1742
Mailing Address - Fax:
Practice Address - Street 1:1135 GREGG HWY NW
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-6341
Practice Address - Country:US
Practice Address - Phone:803-641-7700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-03
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7249101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional